Paediatric Liver Transplantation

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Paediatric Liver Transplantation Using Segmental
Grafts From Controlled Non-Heart Beating Donors
Paolo Muiesan Consultant Surgeon Liver
Transplantation and HPB Surgery Kings College
Hospital, London
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Graft Survival improved due to

• Donor selection
• Short warm and cold ischaemia
• Progressive reduction in PNF
• Shift to controlled donation

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Controlled NHBDs

• Brain injury incompatible with recovery
• Not meeting brain stem death criteria
• No chance for meaningful recovery
• Physician and family elect to withdraw support
• Decision precedes and is independent from that of
  organ donation
• Cardio-circulatory function ceases before
  retrieval
• Death declared by attending physician not
  involved with transplant team

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Donor criteria

• Age 12 months 65 years (case by case)
• Donor Assessment
• Potential donor in ICU
• Planned withdrawal of treatment
• Good liver and renal function
• Expected imminent death
• Paediatric recipients
• Controlled donors lt 40 years of age
• Warm ischaemia time lt 30 minutes
• Short interval from withdrawal to cardiac arrest
• Good appearance and perfusion of the liver

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British Transplantation SocietyNHBD Guidelines -
Declaration of death
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Super rapid technique

• Laparotomy
• Drainage IVC
• Cannulation of aorta
• Preflush with fibrinolytic
• Perfusion with Marshalls with added heparin
• Topical cooling
• Thoracotomy
• Aortic clamping
• Drainage IVC
• Cannulation of SMV
• Perfusion with UW with added heparin
• Slow down
• Look for aberrant vessels

A. Casavilla, Pittsburgh, 1995
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Liver transplants from NHBDsKings College
Hospital

• Donor
• Drainage of IVC before perfusion to avoid
  congestion
• Fibrinolytic preflush
• Low viscosity solution in aorta
• Mild pressure perfusion
• Recipient
• Minimise cold ischaemia
• Reperfusion with hepatic artery
• Reduces the cardio-circulatory effects of
  reperfusion
• Allows a more uniform reperfusion of the graft

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Liver transplants from NHBDsKings College
Hospital
Liver transplants 42 Warm ischaemia 14.9
min Cold ischaemia 8.4 (5-14 hours) PNF or
dysfunction 1 (2.4) Acute rejection 31
Median postop. stay 21 days Patient survival
85.7 Graft survival 83.4 Mean follow
up 20 (1-50 months) Deaths 6 (4 sepsis, 1
cardiac, 1 rejection)
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NHBD livers n.80
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Liver transplants from NHBDsKings College
Hospital
NHBD livers unsuitable suitable Donor age
(years) 46.4 37.2 Donor weight
(Kg) 79.1 71.2 Donor bilirubin
(mmol/L) 14.9 17.5 Donor ALT
(IU/L) 129 110 Donor INR 1.48 1.0 ITU
stay (days) 3.8 3.7 WD to arrest
(min) 42.7 17.0 p 0.04 Warm ischaemia
(min) 17.6 14.5 Liver weight (grams) 1737 1390
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(No Transcript)
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Good Immediate Function
7 h CI
14 h CI
Primary Non Function
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Cell viability using trypan-blue dye exclusion
technique
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Type of liver grafts from NHBDsKings College
Hospital (42 transplants)
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Paediatric NHBD liver recipients
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Paediatric NHBD liver recipients
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NHBD details
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NHBD details
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OutcomeMean follow up 22 months (11-39)

• No mortality
• Postoperative morbidity
• Pleural effusion
• Drainage
• Biliary leak cut surface
• Resolved with percutaneous drainage
• Good liver function

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Liver function
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Impact of NHBD liver transplantationKings
College Hospital
9.3
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Expansion into theNon-Heart Beating Category

• Careful donor selection and short cold ischaemia
• True potential to increase liver graft pool
• Segmental reduction/splitting feasible allowing
  NHBD liver transplantation in children
• Resources required - development education
• Audit early and long term results

23
Third International Meeting on Transplantation
from Non-Heart-Beating Donors
11-12 May, 2006, London